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PUTNAM COUNTY HEALTH DEPAR1MENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
Howard �ragert
296 Ogcawana Rd.
Putnam Valley, NY 14578
OWNER'S NAME K, •VSO h Tg-a- ' PA L co M PHONE
SITE VOCATION �'r BRs�� ST, T IVA-4t iy L-OUbc TO 01� S12 - x061 -01
MAILING ADDRESS U T-i'Gf-* V 69 L L. C- 9 °"j
PERSON INTERVIEWED PCHD Complaint $
Name & Relationship (i.e, owner,tenant, etc.Y �T f
DATE TYPE FACILITY ! f iv, r
PROPOSED. TALLER t, p PHONE 2
Proposal (include sketch locating all adjacent wells):
NONE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect. t
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G >ruc sr� nr6 -PIW(c I &o tas
Proposal approved Proposal Disapproved
Ik
Inspector's Signature & Title Date
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed components tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
(e.g.,house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner or reported ag t of owner agree to the above conditions.
SIGN TITLE 6 pATE I C
PASS: White (P HD); YeUow (fin ED[); Pink (Appliamt)